Failed surgical treatment for lateral epicondylitis: literature review and treatment considerations for successful outcomes.

Background: Lateral epicondylitis is a common cause of elbow pain in the general population. It is recognized as a degenerative tendinopathy of the common extensor origin believed to be multifactorial, involving elements of repetitive microtrauma associated with certain physiologic and anatomic risk factors. Methods: Initial treatment typically involves a combination of conservative treatment measures, with up to 90% success at 12-18 months. Surgical treatment is reserved for recalcitrant disease; traditionally involving open surgical débridement of the common extensor origin with reported success rates greater than 90%. Results: Failure of surgical treatment can be multifactorial and present a challenge in determining the optimum management. Residual symptoms may be due to an incorrect initial diagnosis, inadequate surgical débridement, new pathology as a complication of the initial surgery and/or other patient-related and physician- related factors. Even more of a challenge is the possibility that etiology can be due to a combination of listed factors. Discussion: In this review, we review the classification scheme for evaluating failed surgical treatment of LE first proposed by Morrey and expand on this classification system based on the senior author's experience. We present the senior author's preferred systematic approach to evaluation and management of these patients, as well as a salvage surgery technique used by the senior author to address the most common etiologies of surgical failure in these patients.

Isolated Second and Third Carpometacarpal Joint Injuries: A Report of 2 Cases.

CASES: Two high-level male athletes with isolated second and third carpometacarpal (2, 3 CMC) joint injuries presented with mid-dorsal wrist pain, decreased grip strength, and painful wrist motion. Both reported inciting trauma-1 acutely and the other months after the original injury. Both exhibited 2, 3 CMC joint tenderness and positive provocative testing on exam. Advanced imaging confirmed 2, 3 CMC joint injuries. Both patients returned to preinjury level of play 3 months after diagnosis and surgical treatment. CONCLUSION: 2, 3 CMC joint injuries should be considered when evaluating radial/mid-dorsal wrist pain. Surgical treatments range from pin stabilization to fusion depending on chronicity and associated degenerative joint changes.

Isolated Fourth Carpometacarpal Joint Injury in High-Level Baseball Players: A Case Series.

BACKGROUND: We present a case series of high-level baseball players having sustained a rare, isolated injury to the fourth carpometacarpal joint of the nondominant or bottom hand during a jammed swing. METHODS: Ten patients were evaluated for ulnar-sided wrist pain and were subsequently diagnosed with fourth carpometacarpal joint synovitis based on physical examination and magnetic resonance imaging revealing increased signal intensity within the joint. RESULTS: Conservative treatment modalities including rest, nonsteroidal anti-inflammatory medications, splinting, and corticosteroid injections resulted in return to play within 4 weeks for all patients. CONCLUSIONS: We propose a mechanism of injury involving the bottom hand in relative pronation receiving a dorsally directed force from bat during a jammed swing resulting in isolated injury to the fourth carpometacarpal joint. This report serves to highlight this rare injury in high-level baseball players and recommend a treatment algorithm for early return to play.

Split Brachioradialis Tendon Causing Wartenberg Syndrome in a Professional Baseball Pitcher.

Wartenberg syndrome can occur when external factors compress the superficial radial nerve. It can also be due to anatomic variations, such as a split brachioradialis tendon entrapping the nerve. This case report describes a unique example of a professional baseball player diagnosed with Wartenberg syndrome who was later found to have a split brachioradialis tendon during surgical management. It is an important addition to the field of hand surgery since, to our knowledge, we have not identified such a rare case concerning a professional athlete previously described in the literature.

Finger Metacarpophalangeal Joint Injuries in Athletes: Evaluation, Diagnosis, Treatment, and Return to Play.

Metacarpophalangeal (MCP) joint injuries of the fingers are frequent among athletes and can markedly affect an athlete's ability to perform at a high level. Despite this, MCP finger injuries in athletes are not frequently discussed, particularly in comparison with MCP joint injuries of the thumb, and remain unrecognized and undertreated injuries in this cohort. Accurate diagnosis and treatment of these injuries begins with an understanding of all the potential diagnoses. The purpose of this study was to review the pertinent anatomy and differential diagnoses for MCP joint injuries in athletes, including the evaluation and management to allow for safe and early return to play.

Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment.

Finger injuries involving the proximal interphalangeal (PIP) joint are common, particularly among athletes. Injury severity is often underappreciated at initial presentation and may be dismissed broadly as a "jammed finger" injury. Delayed diagnosis and treatment of certain injuries can have an important impact on the patient's chance of regaining full function. Central slip and PIP volar plate injuries are frequently encountered injuries that, if left untreated, can lead to the permanent loss of function of the proximal interphalangeal joint. Despite the differing mechanisms of these 2 pathologies, volar plate hyperextension injuries often present with a PIP joint flexion contracture and mild distal interphalangeal joint hyperextension deformity. This is similar to a boutonniere deformity seen after an injury to the central slip, and thus, has been referred to as a "pseudo-boutonnière" deformity. Distinguishing these 2 diagnoses is important, as treatment differs, and highlights the importance of thoroughly understanding the anatomy and relevant clinical applications when evaluating PIP joint injuries.

A Combined Revision Surgical Technique for Failed Operative Lateral Epicondylitis With Concomitant Radial Tunnel Syndrome.

Lateral epicondylitis afflicts a large percentage of the population with most recovering through conservative treatment. The 5% to 10% of patients who undergo operative intervention are met with mixed results. Those that fail to improve often demonstrate a complex presentation of inadequate debridement of the "angiofibroblastic tissue," missed concomitant radial tunnel syndrome, and iatrogenic residual devascularized tissue resulting from the index procedure. To address all 3 of these causes of failure, the authors have developed a revision procedure that includes repeat debridement of residual tendinosis, decompression of the posterior interosseous nerve, and a vascularized anconeus muscle flap to help cushion soft tissue defects and promote a healthier environment for healing. Performed initially in part in 20 patients, this combined procedure has developed into our recommended treatment for these challenging patients.

Middorsal Wrist Pain in the High-Level Athlete: Causes, Treatment, and Early Return to Play.

Wrist injuries in the competitive athlete are a common reason for evaluation related to an acute injury or after symptoms have become chronic. While radius- and ulna-sided wrist pain are common topics covered in the literature, middorsal wrist pain is more common than the available literature would suggest. Missed diagnoses and inadequate treatment can significantly increase athlete morbidity and delay return to play. The goal of this article was to review the differential diagnosis of middorsal wrist pain in the athlete and discuss the diagnosis, treatment, and early return to play for each condition.

Pressures Exerted on the Hook of the Hamate in Collegiate Baseball Players: A Comparison of Grips, With Emphasis on Fracture Prevention.

BACKGROUND: Variations in batting technique may put baseball players at increased risk of hook of the hamate fractures. A better comprehension of the mechanism of such fractures is needed. PURPOSE/HYPOTHESIS: The purpose of the study was to compare 2 different grip types to quantify the pressures exerted on the hook of the hamate during batting. It was hypothesized that when compared with the conventional batting style, players holding the knob of the bat in the palm of the hand (termed the "palmar hamate grip") would have higher pressures exerted on the hook of the hamate. STUDY DESIGN: Controlled laboratory study. METHODS: Athletes were recruited for participation on a volunteer basis from the rosters of 2 National Collegiate Athletic Association Division I baseball teams and were divided into 2 groups based on their usual grip type. A force sensor system was applied to the nondominant hand of each participating player, with the central portion of the sensing mechanism placed on the batting glove directly over the hook of the hamate. All players used the same batting glove, which transmitted data from the sensor to a laptop computer. Measurements were collected on consecutive hits at a standardized distance using a ball machine at 70 mph. RESULTS: Nine collegiate baseball players underwent testing (5 players exclusively used the conventional grip, 3 players exclusively used the palmar hamate grip, and 1 player naturally alternated between the 2 grip types). The palmar hamate grip demonstrated a 366% increase in pressure exerted on the sensor overlying the hook of the hamate when compared with the conventional batting grip (536.42 kPa [95% confidence interval, 419.39-653.44 kPa] vs 115.84 kPa [95% confidence interval, 96.97-135.10 kPa]). The player who used both grips demonstrated significantly higher maximum pressure when using the palmar hamate versus conventional grip (482.90 vs 142.40 kPa; t = 6.95; P < .0001). CONCLUSION: Use of the palmar hamate grip may increase the risk of hook of the hamate fracture in National Collegiate Athletic Association Division I baseball players. CLINICAL RELEVANCE: Educating players on the risks associated with the palmar hamate grip may prevent injury and minimize time out of competition.

Lacertus syndrome: Use of pre- and post-exercise MRI to aid in diagnosis and treatment.

Lacertus syndrome is a chronic exertional compartment syndrome of the forearm that is unlike exertional compartment syndrome of the lower extremity. It differs from traditional exertional compartment syndrome in terms of the anatomy, symptoms and physical exam findings. This is a case where dynamic magnetic resonance imaging is used to confirm the diagnosis rather than relying solely on a clinical diagnosis or invasive compartment pressure monitoring. Surgical release of the lacertus fibrosis can effectively relieve the pressure over the pronator and allow the patient to resume previous activities.

Ulnar nerve dysfunction at the elbow after platelet-rich plasma treatment for partial ulnar collateral ligament injuries.

Background: Platelet-rich plasma (PRP) has been used for the treatment of partial ulnar collateral ligament (UCL) tears of the elbow in throwing athletes. Very few studies have focused on the complication profile of PRP in this application.The purpose of this study was to discuss the complication of ulnar nerve fibrosis and resulting cubital tunnel syndrome after a PRP injection for a partial UCL injury. Methods: A retrospective review of 3 high-level baseball players who underwent a PRP injection for treatment of their partial UCL injury was completed. All 3 were noted to have an asymptomatic subluxing ulnar nerve at time of presentation. Their postinjection course is discussed, and the complication of cubital tunnel syndrome highlighted. Results: All 3 players developed cubital tunnel syndrome with significant fibrosis surrounding their ulnar nerve. Conclusion: PRP injections for the treatment of partial UCL injuries of the elbow may place some patients at risk of developing postinjection cubital tunnel syndrome from increased fibrosis around the ulnar nerve. This complication may be more likely to develop in patients who present with a subluxing ulnar nerve.

Suture Tape Augmentation for Scapholunate Ligament Repair: A Biomechanical Study.

PURPOSE: Scapholunate (SL) ligament tears in the acute setting can be treated by primary repair through various techniques. The purpose of this study was to compare repair of the SL ligament with suture anchors alone versus repair of the SL ligament augmented with suture tape. METHODS: Twelve fresh-frozen cadavers (6 matched pairs) underwent a dorsal approach to the wrist and the SL ligament was sharply dissected off of its scaphoid attachment. Six cadavers underwent direct repair of the SL ligament using 2 suture anchors. The other 6 underwent repair of the SL ligament, which was then augmented with suture tape. All specimens then underwent load to failure testing using tensile distraction forces applied by a universal testing system. Maximum load to failure and mode of failure were recorded. RESULTS: Maximum load to failure (135 N; SD, 44.94 N) for specimens that were repaired and augmented with the internal brace was higher than that for specimens in the repair-only group (68 N; SD, 14.69 N). CONCLUSIONS: Biomechanical testing demonstrated a higher maximum load to failure in SL ligament repairs augmented with suture tape compared with a repair-only technique in this cadaveric model. CLINICAL RELEVANCE: Acute SL ligament injuries may benefit from suture tape augmentation by increasing the stability of the primary repair. This may prove to be beneficial in higher-demand patients.

Locked Wrist: A Case Report and Literature Review on Pisotriquetral Loose Bodies.

Background Pisotriquetral (PT) loose bodies have been described in the literature only a few times as case reports. While PT pathology remains the differential for ulnar-sided wrist pain, it can often be difficult to diagnose, as symptoms can be variable and radiographic imaging may be negative for any findings. Case Description A 24-year-old major league baseball player presented with pain and locking of his wrist during follow through of his bat swing. Plain radiographic imaging, as well as computed tomography (CT) imaging, was negative for any pathology. Dynamic magnetic resonance imaging (MRI) demonstrated a loose body which entered the PT joint when the wrist was moved into a flexed position. This caused entrapment of the loose body and locking of the wrist. Literature Review A total of 17 reported patients in the literature have been diagnosed with a PT loose body. The clinical examination findings, radiographic findings, and surgical findings are reviewed. Case Relevance PT loose bodies can present a challenging clinical picture to diagnose. The purpose of this case report is to review the appropriate clinical workup, including common examination findings and advanced imaging techniques, to help the clinician with the diagnosis.

Performance and Return to Sport After Excision of the Fractured Hook of the Hamate in Professional Baseball Players.

BACKGROUND: A fracture of the hook of the hamate is a common injury affecting professional baseball players. The treatment for these fractures ranges from nonoperative immobilization to excision of the fragment. PURPOSE/HYPOTHESIS: The purpose was to report the results of surgical treatment of hook of hamate fractures in professional baseball players and determine which factors are associated with return to sport (RTS) and time to RTS. The hypothesis was that there is a high rate of RTS in professional baseball players after surgical treatment of the hook of the hamate fracture with no significant decline in performance after RTS. STUDY DESIGN: Descriptive epidemiology study. METHODS: All professional baseball players who underwent excision of the hook of the hamate between 2010 and 2017 were included. Player characteristic and performance data (before and after surgery) were recorded. Performance metrics were then compared before and after surgery. RESULTS: Overall, 261 players were included. Of total injuries, 96% were due to hitting, 86% occurred on the nondominant hitting side, and 89% were acute fractures (11% were nonunion cases). Most (95%) injuries occurred at the Minor League level and 96.2% of procedures were performed by hand fellowship-trained surgeons. Eight percent of players underwent concomitant procedures. The average tourniquet time was 31 ± 13 minutes. In total, 81% of players returned to sport at the same or higher level; 3% returned to sport at a lower level. The median time to RTS after surgery was 48 days (range, 16-246 days). The tourniquet time and number of days to RTS were significantly associated with one another (P = .001; Spearman ρ = 0.290; N = 130). Player utilization significantly increased after surgery. While player efficiency, including batting average (BA), on-base percentage (OBP), and on-base plus slugging percentage (OPS), significantly decreased, these changes were numerically small (BA: 0.26 ± 0.04 preoperatively vs 0.25 ± 0.04 postoperatively; OBP: 0.34 ± 0.04 preoperatively vs 0.32 ± 0.04 postoperatively; OPS: 0.73 ± 0.12 preoperatively vs 0.70 ± 0.11 postoperatively) (P < .001). There were no significant differences between rates of RTS to the same or higher level of play among acute fractures (81%) and nonunion cases (76%) (P = .837). CONCLUSION: After surgical excision for hook of hamate fractures in professional baseball players, 84% were able to RTS, with 81% returning to the same or higher level. The median time for players to RTS after surgery was 48 days. Player usage increased after surgery, while hitting efficiency slightly declined.

Cubital tunnel syndrome: a surgical modification to in situ decompression to improve results.

BACKGROUND: The gold standard for surgical treatment of cubital tunnel syndrome is in situ decompression. However, this procedure does not come without complications. Subluxation of the ulnar nerve and ulnar nerve neuritis from adhesion formation remain 2 potential complications after this procedure. It has been shown in the literature that young, active, male patients are most likely to have these complications postoperatively. We have developed a modification to in situ decompression by developing a fascial turnover flap and using a porcine submucosa extracellular matrix (Axogen) to help reduce both ulnar nerve subluxation and adhesion formation postoperatively. METHODS: Thirteen patients underwent cubital tunnel surgery by the highlighted technique to prevent postoperative ulnar nerve subluxation and adhesion formation. Patient outcomes including elbow range of motion, functional status, paresthesia, and grip strength were recorded. RESULTS: Of the 13 patients, 10 had excellent results, 1 had a good result, and 2 required revision with anterior transposition of the nerve. The mean Mayo Elbow Performance Score of the 11 patients not needing revision was 92.7. CONCLUSION: The described surgical technique provides surgeons with the ability to directly decompress the ulnar nerve while decreasing postoperative complications such as instability and adhesion formation.

Dynamic Nerve Compression of Guyon Canal Secondary to Variation of the Deep Branch of the Ulnar Artery: Etiology, Diagnosis, Treatment, and Outcome.

A patient presented with an ulnar-sided left wrist injury that was sustained while batting. Advanced imaging was obtained to rule out common causes of nerve compression and evaluate the patient's anatomy. Dynamic nerve conduction studies were necessary to confirm a diagnosis of nerve compression. Failing conservative treatments, the patient underwent exploration of Guyon canal and decompression of the ulnar nerve with complete symptom resolution. The patient presented a unique diagnostic challenge because he did not display the typical findings of chronic nerve entrapment syndromes. To the best of our knowledge, dynamic nerve compression at Guyon's canal has not previously been described. It is important to use a systematic approach to diagnosis, eliminating all other sources of compression. With appropriate diagnostic tools, nerve decompression can result in symptom relief.

Dysfunction of the Lateral Branch of the Superficial Radial Nerve Associated with Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint: A Case Series with Cadaveric Dissections.

The lateral branch of the superficial radial nerve (SRN) may undergo a neuropraxic stretch injury following radial collateral ligament (RCL) injury to the thumb metacarpophalangeal joint. This case series presents seven athletes who sustained a previously undescribed injury pattern combining dysfunction of the lateral branch of the SRN associated with RCL injury. Successful stabilization of the joint as well as relief of pain was obtained with surgical repair of the RCL, neurolysis and wrapping of the nerve with a tissue engineered allograft product, and, when necessary, excision of a post-traumatic osteophyte. Diagnostic workup along with surgical treatment is presented. Additionally, cadaveric dissections confirmed the course of this nerve, proximity to surrounding structures, and its innervation of the MP capsule. (Journal of Surgical Orthopaedic Advances 29(4):195-198, 2020).

Trapeziometacarpal Fusion With and Without Distal Scaphoid Excision: A Cadaveric Model Comparing Thumb Range of Motion.

Purpose: To describe the biomechanical changes seen after thumb carpometacarpal (CMC) fusion with distal scaphoid excision (DSE), a surgical technique used for pantrapezial disease in high-demand individuals. Methods: A cadaveric study with 13 fresh-frozen cadaveric specimens was conducted. Fluoroscopic measurements in posteroanterior (PA) and lateral planes were performed. Thumb CMC fusion was then simulated. The same images were taken after fusion. The distal scaphoid was excised, and the measurements were obtained again. The angle between the index finger and thumb metacarpals was recorded. Statistical analysis was performed using Wilcoxon signed rank test. Results: The mean arcs of motion in the PA plane pre-fusion, post-fusion, and post-fusion with DSE were 48.5°, 25.1°, and 34.6°, respectively. An increase in arc of 9.5° was obtained after DSE compared with thumb CMC fusion alone. The mean arcs of motion in the lateral plane pre-fusion, post-fusion, and post-fusion with DSE were 53.4°, 22.4°, and 33.6°, respectively. A statistically significant increase in arc of motion of 11.2° in the lateral plane was obtained after DSE compared with thumb CMC fusion alone. This was a 20% and 21% increase in pre-fusion range of motion in the PA and lateral planes, respectively, from fusion alone compared with fusion and DSE. Conclusions: Thumb CMC fusion combined with DSE maintains motion lost in simple CMC arthrodesis.

MRN findings of lateral antebrachial cutaneous nerve impingement in a collegiate athlete.

Dynamic compression of the lateral antebrachial cutaneous nerve (LABCN) occurs with forearm pronation when the LABCN becomes compressed by the lateral margin of the biceps tendon. LABCN compression is a rare occurrence and is often overlooked as an etiology for forearm pain. While this entity has been described in several case reports in the orthopedic literature, it has not yet been described in radiology literature. We present a case of LABCN compression by the biceps tendon which was suggested by high-resolution magnetic resonance neurography in combination with the clinical findings and was subsequently confirmed and corrected surgically.